Thursday, June 9, 2011

Just got back from a dinner function at the 9th International Conference on Bipolar Disorder in Pittsburgh. A few quick observations before I hit the sack:

At the opening session on Medical Life Style Management, Fouzia Laghrissi-Thode of Hoffman-La Roche advised that we have to look away from psychiatric conditions as isolated conditions. Rather, we are talking about systemic illnesses, involving many systems. Other speakers on the panel made much the same observations, pointing out the interconnections involving cardiovascular and metabolic diseases, bad sleep, mood disorders, and no end of other stuff. Said Michael Ostacher of Stanford, our focus needs to shift from solely on improving mood to improving well-being.

The second session involved the DSM-5. The panel, comprising members and consultants on the work group responsible for coming up with changes to the bipolar diagnosis, all pointed out that mood disorders existed on a spectrum, “analogous to blood pressure,” as legendary Swiss diagnostician Jules Angst put it. Dr Angst pointed out three dimensions to the spectrum: 1) from depression to mania 2) severity (from “normal” to pronounced symptoms) 3) temperament (a permanent condition over a lifetime).

The catch though, said Ellen Frank of the University of Pittsburgh, was that although the reality is not categorical, the DSM has to be in order to give names and provide cut-off points. Major catch. Is a “mixed” depression, for instance mandate at least two mania symptoms or three? Is two days long enough for hypomania or should it be four?

A couple of psychiatrists I talked to later compared the exercise to counting angels on the head of a pin. The distinctions were way too subtle for the real world of clinical practice, they pointed out. The research psychiatrists I talked to stressed they need these fine distinctions for research purposes. Why can’t they make it simple, I asked one research psychiatrist - feeling good-feeling shitty. The clinical terms are euphoric-dysphoric.

I’ve been very critical of the DSM-5 on this blog, but I want to point out that the experts on the panel over the years, in particular Ellen Frank and Trisha Suppes of Stanford, have been very helpful to me in pointing out the ins and outs of the mood spectrum, mixed states, and the many faces of hypomania. But nothing I heard today alters any of my previous criticisms.

After lunch, Nora Volkow, head of the National Institute of Drug Abuse, delivered a tour-de-force presentation on the fine points of everything about the brain. The brain doesn’t work in isolation, she noted. The brain works in networks. The brain takes 20 years to develop as opposed to the heart. Genetic time-bombs may be triggered anywhere from the fetus to right now. Our genetic predisposition to how we react to the environment may determine whether our behavior is controlled or automatic. In essence, when things go wrong, the prefrontal cortex fails to effectively modulate the amygdala.

“Resting functional connectivity” - you will hear a lot more on that in future blog posts, along with an area of the brain called the “habenula.”

Another session on circadian rhythms and brain imaging, poster session, chill break, dinner function. I run into my longtime friend Bill Ashdown from Canada, very active in international advocacy, great catching up.

On the DSM -- preaching to the choir here, but two observations about what is at stake:

1 - It's fine for people researching bipolar to define a set of really, really bipolar people to study. Like, we don't know the limits of what an apple is, so we are only going to study red apples. The problem is that leaves this group called "everybody else" -- pears and yellow apples. The yellow apples confuse the results, because applying the DSM criteria, nobody can pick them out. Not to mention learn anything about them.

2 - Meanwhile, as we dither, yellow apples are being treated like pears. Family practitioners feel perfectly competent to treat major depression. They do not feel competent to treat bipolar. The DSM does not help them tell the difference between the two. Of course, everybody likes to beat up on family practitioners. But three psychiatrists, referring to the DSM, misdiagnosed me, too.

As a person with bipolar II, what is at stake is a LOT of human suffering, insomnia, suicidal impulses, akathesia. Slip a little akathesia into these people's cocktails and THEN talk about the DSM!

Okay, one more shot. The problem is not "where to draw the line." It's about the more basic, "how do we conceptualize this animal?" DSM V is locking in polarity, not cycling as the essential feature to distinguish mood disorders. Is anybody with any pull (sorry, John) challenging that starting point? Or is this a done deal and forget about it for another decade?

Hi all. I am new to this site but I think it is hugely helpful - wish I had found it 18 months back when I fell into the wild world of bipolar disorder (rather spectacularly, but that's a story for another day). Glad to know there's someone out there who really gets it trying to help sort out the complexity and just maybe help the "learned professionals" get it right. Because there's nothing like first-hand experience to really understand something. And taking someone from a crisis state does not constitute a cure, although I'm pretty sure the psychiatrists that work in hospitals consider themselves heros. They are really emergency room docs - they definately have a place, but as my husband says, they are "necessary but not sufficient". Okay this is turning into a rave. The take home message I was shooting for is: keep up the great work you are doing and thank you. I will look forward to more of you analysis and insights from the conference.

Every kind of clinical medical research excludes something, ie research on new chemotherapy drugs in human clinical trials will usually exclude people with heart problems as well as cancer. But those people still get treated. The problem is the DSM is used for far more than research, especially once the insurance companies poke their noses in.

And nonpsychiatrist docs will use it as a reference, not realizing the limitations. And its definitions of illness are taught in Nursing school even tho they are woefully incomplete.

And the authors are STILL NOT LISTENING TO US.

Since we still have little to no objective measurements of our illness, one would thing listening is essential. Please keep talking for us.